PLUNGING RANULA- A CASE REPORT.(Deep, diving or a cervical ranula)

A "Plunging Ranula" , is an extravasation of saliva from the sublingual gland due to trauma or obstruction of the duct. Fluid from the obstructed gland dissects between the fascial planes and muscle of the base of the tongue into the submandibular space. This is a case report of a young lady, that after diagnosis was surgically excised via a Trans Cervical Incision, Sub-mandibular approach. Soft tissue reconstruction was done via primary closure.

1. PLUNGING RANULA (A CASE REPORT) Dr . Riffat Khattak Associate Surgeon –ENT FGPMI, Islamabad.

2. CASE PRESENTATION

3. CASE REPORT Patient’s name : XYZ Age : 18 Years Presentation : Presented with an intermittently enlarging swelling in the floor of the mouth and the neck for the last six weeks with difficulty in speech

4. CASE REPORT Oral Cavity Examination : A huge globular mass with a bluish hue in the sublingual compartment pushing the tongue upwards and backwards Neck Examination : A huge globular, mobile swelling, measuring about 5x6 cm in size in the submandibular region, non-tender, with normal looking overlying skin No clinically palpable neck nodes

5. CASE REPORT

6. DIAGNOSIS

7. RADIOLOGICAL FINDINGS ULTRASONOGRAPHY

8. RADIOLOGICAL FINDINGS ULTRASONOGRAPHY

9. RADIOLOGICAL FINDINGS COMPUTED TOMOGRAPHY SCANS

10. RADIOLOGICAL FINDINGS CT SCANS Clearly demonstrates an oral and a cervical part of a plunging ranula

11. HISTOPATHOLOGICAL FEATURES Low power view of the Ranula wall, lined by granulation tissue and filled with mucin and histiocytes

12. BASELINE INVESTIGATIONS Hb= 12.5g/ dL TLC= 9500/microliter Platelet count = 1,22,000/ microliter Hepatitis B & C : Negative LFT’s, RFTs, SE, BSR : WNR Blood Group: O +ive

13. TREATMENT

14. SURGICAL EXCISION Surgical excision of the Plunging Ranula via a trans-cervical incision, Submandibular approach with the complete excision of the sublingual salivary glands was done Soft tissue reconstruction was done via primary closure Drain was removed after 72 hours post-operatively Complete healing of the wound occurred after two weeks without any complications

15. DISCUSSION

16. HISTORY The term “ranula” is derived from the Latin word “Rana”, meaning “Frog” and describes a blue translucent swelling in the floor of the mouth, reminiscent of the underbelly of a frog Hippocrates described ranulas and thought they were secondary to inflammation Par’e thought that ranulas may represent descent of brain or the pituitary matter

17. INTRODUCTION A plunging ranula is an extravasation of saliva from the sublingual gland due to trauma or obstruction of the duct Fluid from the obstructed gland dissects between the fascial planes and muscle of the base of the tongue into the submandibular space

18. INTRODUCTION The exact prevalence of plunging ranula is not known, however, these lesions are considered uncommon Because most plunging ranulas either accompany a swelling in the floor of mouth or are associated with a history of treatment of intraoral ranula, it is not difficult to diagnose such a lesion

19. INTRODUCTION On the other hand, the plunging ranulas in which there is no clinical evidence of an oral connection, needs a diagnostic acumen The purpose of this Case Report is to present clinical and radiographic findings of a rare case of plunging Ranula

20. EPIDEMIOLOGY Ranulas rarely occur In a study of 1303 salivary gland cysts , only 42 were ranulas The reported male to female ratio is 1:1.3 There is no significant side preference

21. EPIDEMIOLOGY Presents most frequently in the 2nd and 3 rd decades of life with an age range of 3-61 years Plunging ranulas occur less commonly than simple ranulas Only slightly more than 100 well documented cases of plunging ranulas have been reported in the English Literature

22. TYPES OF RANULAS (a) SIMPLE RANULAS : Confined to the Sublingual space in the Oral Cavity (b) PLUNGING RANULAS: Extend through the myelohyoid muscle into the submandibular space in the neck

23. ETIOLOGY (a) RANULAS Congenital ranulas arise secondary to an imperforate salivary duct or ostial adhesion Post-traumatic ranulas arise from trauma to the sublingual gland, leading to mucus exravasation and formation of a “Pseudocyst ”

24. ETIOLOGY (b) PLUNGING RANULAS Also called as the deep, diving, cervical or the deep plunging ranula and the oral ranula with a cervical extension They arise in conjunction with the oral ranulas Patients present first with an oral swelling in up to 45% of the cases and without oral involvement in 21% of the cases

25. PATHOPHYSIOLOGY

26. PATHOPHYSIOLOGY (a) RANULAS Partial obstruction of a sublingual duct can lead to the formation of an epithelial lined retention cyst ( occurs in less than 10% of the ranulas) Trauma : Partial severance or ligation of the sublingual duct leads to mucus extravasation and ranula formation

27. PATHOPHYSIOLOGY (b) PLUNGING RANULAS They arise in the neck by 3 mechanisms : The sublingual gland may project through the myelohyoid or an ectopic sublingual gland may exist on the cervical side of the myelohyoid The cyst may penetrate through the myelohyoid A duct from the sublingual gland may join the submandibular gland or its duct

28. DIAGNOSIS Ultrasonogram Lateral Oblique projection of the sub-mandibular region with contrast medium injected in the sublingual space Computed Tomography Scans( with contrast) Magnetic Resonance Imaging Histopathological features after the excision of the lesion

29. DIFFERENTIAL DIAGNOSES Thyroglossal duct cyst Branchial cleft cyst Cystic hygroma Submandibular sialadenitis Intramuscular hemangioma Cystic or neoplastic thyroid disease Infectious cervical lymphadenopathy (Epstein-Barr virus, cat scratch disease, tuberculosis)

30. DIFFERENTIAL DIAGNOSES Hematoma Lipoma Laryngocele Dermoid Cyst

31. TREATMENT OPTIONS Excision of the ranula only Cryosurgery Marsupialization with or without cauterization of the lesion lining Excision of the oral portion of the ranula with the associated sublingual salivary gland or, rarely, the submandibular gland

32. TREATMENT OPTIONS Intraoral excision of the sublingual gland and drainage of the lesion Excision of the lesion via a cervical approach, sometimes combined with excision of the sublingual gland

33. INCIDENCE OF RECURRENCE WITH VARIOUS TREATMENT MODALITIES Incision and drainage = 70% recurrence Marsupialization = 53% recurrence Excision of the lesion in the neck= 85% recurrence Excision of the lesion in the neck and sublingual gland= 3.8% recurrence Intraoral excision of the sublingual gland and drainage of the cyst = 0% recurrence

34. Complications of the various surgical procedures

35. CONCLUSION Though the cases of plunging ranula have been documented with moderate frequency, failure to differentiate the clinical features of oral and plunging ranulas may be a diagnostic pitfall These lesions may be difficult to differentiate from benign and malignant salivary gland tumors A thorough series of radiological, biochemical, and histopathological investigations should be carried out for all cases of suspected plunging ranulas

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38. REFERENCES . [11] M. J. Shelley, K. H. Yeung , N. B. Bowley , and K. J. Sneddon , “A rare case of an extensive plunging ranula: discussion of imaging, diagnosis, and management,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics , vol. 93, no. 6, pp. 743–746, 2002. [12] T. Takimoto , “Radiographic technique for preoperative diagnosis of plunging ranula,” Journal of Oral and Maxillofacial Surgery, vol. 49, no. 6, p. 659, 1991. [13] S. K. Charno ff and B. L. Carter, “Plunging ranula: CT diagnosis,” Radiology, vol. 158, no. 2, pp. 467–468, 1986. [14] P. M. Som and M. S. Brandwein , “Salivary glands: anatomy and pathology,” in Head and Neck Imaging, P. M. Som and H. D. Curtin, Eds., pp. 2067–2076, Mosby, St Louis, Mo, USA, 2003 [15] Y. Yoshimura, S. Obara , T. Kondoh , S.-I. Naitoh , and S. R. Schow , “A comparison of three methods

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